OB/GYN

Rapid Review

• Background
  • Implantation of a fertilized ovum outside the uterusT The fallopian tube is the most common.
  • Occurs in about 2% of all pregnancies and accounts for 6% of all maternal deaths.
• Signs/Symptoms
  • Vaginal bleeding, abdominal/pelvic pain, adnexal mass, amenorrhea
  • Rupture of ectopic pregnancy can cause hypotension, syncope, and peritonitis 
• Diagnosis
  • Beta HCG > 1500, but no signs of intrauterine pregnancy on transvaginal ultrasound.
  • If beta-hCG levels rise, but do not double over the course of 48 hours, then it is likely an ectopic pregnancy.
• Treatment
  • Resuscitate, give RhoGAM to Rh ( -) women, consult OB/GYN
  • Methotrexate (unless contraindicated). Surgery may be needed.

Pearls

Deep Dive

• Ectopic Pregnancy (SAEM)

Rapid Review

• Background
  • Endometriosis is the presence of endometrial tissue implanted outside the uterus (pelvic cavity, uterine ligament, bowel, lungs, ovaries, etc.)
  • Most common site is the ovaries
• Signs/Symptoms
  • “Three D’s” (dyspareunia, dyschezia, dysmenorrhea)
  • Often presents asymptomatically or with pelvic pain before/during menses
• Diagnosis
  • Laparoscopy and biopsy required for definitive diagnosis 
• Treatment
  • Analgesics (NSAIDS)
  • Hormone therapy (danazol, oral contraceptives, progestins, GnRH agonists, aromatase inhibitors)

Pearls

Deep Dive

• Endometriosis (Merck Manual)

Rapid Review

• Background
  • Fluid-filled sac within the ovary. Generally benign, but can lead to torsion, rupture, hemorrhage, or infection.
  • Follicular cysts are the most common; other types include corpus luteum cysts (can cause rapid bleeding) and Theca lutein cysts (seen in pregnancy) 
• Signs/Symptoms
  • Most are asymptomatic; common symptoms include lower abdominal pain, bloating, and dyspareunia.
  • If ruptured, can cause significant pain, hypotension, tachycardia
• Diagnosis
  • Transvaginal ultrasound
  • Masses > 5 cm concerning for ovarian torsion
• Treatment
  • Most cysts < 5cm resolve on their own. Provide NSAIDs for analgesia
  • Surgery required for complicated cysts

Pearls

Deep Dive

• Benign Ovarian Masses (Merck Manual)

Rapid Review

• Background
  • Acute, bacterial infection that ascends from cervix/vagina to the upper genital tract (uterus, fallopian tubes, ovaries, and adjacent structures)
  • Most commonly caused by Chlamydia trachomatis
• Signs/Symptoms
  • Lower abdominal pain, fever, vaginal discharge/bleeding
  • (+) “Chandelier sign” (cervical motion tenderness), (+) mucopurulent cervicitis
• Diagnosis
  • Clinical diagnosis
  • Must have tenderness (abdominal, uterine, adnexal, or cervical) + one more criteria (fever, discharge, elevated ESR/CRP, documented GC/Chlamydia infection)
• Treatment
  • Antibiotics (ex. ceftriaxone + doxycycline +/- metronidazole)
  • Treat infected partners

Pearls

Deep Dive

• Pelvic Inflammatory Disease (WikEM)

Rapid Review

• Background
  • Hemorrhage caused by premature separation (partial or full) of implanted placenta from the uterine wall after 20 weeks gestation.
  • Often associated with trauma; most common cause of third trimester bleeding
• Signs/Symptoms
  • Painful vaginal bleeding is the most common sign, but may not always be present. 
  • May have tender uterus and signs of shock
• Diagnosis
  • Clinical diagnosis
  • Ultrasound may help identify retroplacental bleeding
• Treatment
  • Stabilize (ABC’s, blood products, RhoGAM). Consult OB/GYN emergently
  • Definitive treatment is delivery of the fetus/placenta. 

Pearls

Deep Dive

• Placental Abruption (emDOCs)